Diagnosis of venous thromboembolism in pregnancy

Predictive value of prenatal ultrasound combined with long non-coding RNA CRNDE of women for their postpartum lower extremity deep venous thrombosis

OBJECTIVE

Deep vein thrombosis (DVT) is a common complication in obstetrics that needs early interaction. The study examined the expression change and clinical value of long non-coding RNA (lncRNA) colorectal neoplasia differentially expressed (CRNDE) in DVT early diagnosis.

METHODS

One hundred patients with DVT after delivery and 100 healthy parturients without DVT were enrolled. Serum samples were collected one day before delivery and received qRT-PCR for mRNA detection. Prenatal coagulation markers including prothrombin time (PT), activated partial prothrombin time (APTT), fibrinogen (FIB) and thrombin time (TT), D-dimer (D-D), thrombomodulin (TM), and peroxidase anti-peroxidase soluble complex (PAP) were tested. The receiver operating characteristic (ROC) curve was drawn for the diagnostic value assessment.

RESULTS

LncRNA CRNDE levels increased remarkably in the serum of DVT patients compared with the healthy controls, which were negatively correlated with serum concentration of PT, APTT, and TT while positively correlated with FIB, D-D, TM, and PAP. Serum CRNDE (HR = 5.973, 95% CI = 2.990-11.933, p < .001) was independently related to the occurrence of DVT after delivery. Then, ROC curve using serum CRNDE showed a good diagnostic value for DVT with the AUC of 0.899. ROC curve of ultrasonography combined with CRNDE produced an AUC of 0.968, and both sensitivity and specificity were enhanced compared to a single indicator.

CONCLUSIONS

The increase of CRNDE level was an independent risk factor for postpartum DVT. Prenatal ultrasonography combined with CRNDE can improve the predictive efficacy for DVT.

Rare deep vein thrombosis in pregnancy and puerperium 3 case series; upper extremities vein thrombosis, ovarian vein thrombosis, portal and superior mesenteric vein thrombosis

Pregnancy induces a hypercoagulable state, elevating thrombosis risk by 5-6 times compared to non-pregnant conditions. Predominantly affecting the left lower extremity due to anatomical and hematological factors, deep vein thrombosis can escalate into pulmonary embolism, impacting mortality. The authors aim to report rare incidents of thrombosis beyond the norm, including upper extremity vein thrombosis, right ovarian vein thrombosis, and portal vein and superior mesenteric vein thrombosis, highlighting their significance. Obstetricians should be mindful that thrombosis can occur not only in the lower extremities but also in other areas. Especially when symptoms such as fever unresponsive to antibiotics, atypical pain, and an abnormally high C-reactive protein level are present. Considering the possibility of a rare thrombosis is crucial. Understanding these less common thrombotic events during pregnancy and the postpartum period can contribute to the improvement of timely diagnosis and management strategies.

Risk of neonatal hypothyroidism in newborns from mothers exposed to CTPA during pregnancy: Ancillary data from a prospective outcome study

BACKGROUND

Neonatal hypothyroidism is often raised as a potential concern for the use of computed tomography pulmonary angiography (CTPA) in pregnant women with suspected pulmonary embolism (PE).

OBJECTIVES

To assess the incidence of neonatal hypothyroidism among newborns from mothers exposed to CTPA.

PATIENTS/METHODS

Pregnant women with clinically suspected PE were included in a multicenter, multinational prospective diagnostic management outcome study, based on pretest clinical probability assessment, high-sensitivity D-dimer testing, bilateral lower limb venous compression ultrasonography, and CTPA. Results of Guthrie tests were systematically collected for newborns of all women who required CTPA as part of the diagnostic strategy. A thyroid-stimulating hormone (TSH) level above 15 U/ml was used to define hypothyroidism.

RESULTS

Out of the 166 women included in the Swiss participating centers, 149 underwent a CTPA including 14 with twin pregnancies. Eight women suffered a pregnancy loss and results of the Guthrie test could not be retrieved for four newborns. All TSH levels were reported as being below 15 U/ml. The incidence of neonatal hypothyroidism was 0/151 (0.0%, 95% confidence interval: 0.0%-2.5%).

CONCLUSIONS

We did not identify any cases of neonatal hypothyroidism in our cohort of 149 pregnant women investigated for suspected PE using a CTPA. Along with previous literature data, this provides further reassuring data regarding the use of CTPA in this indication.

Approach to Thrombophilia in Pregnancy-A Narrative Review

Thrombophilia is a genetic predisposition to hypercoagulable states caused by acquired haemostasis conditions; pregnancy causes the haemostatic system to become hypercoagulable, which grows throughout the pregnancy and peaks around delivery. Genetic testing for thrombophilic gene mutations is evaluated using different methodologies of real-time polymerase chain reaction and DNA microarrays of specific genes. Adapting the general care of the pregnant woman to the particularities caused by thrombophilia is an important component, so screening is preferred to assess the degree of genetic damage that manifests itself as a risk of thrombosis. The major goal of this narrative review was to quantitatively evaluate the literature data on the specific care of pregnant women with thrombophilia that are at risk of developing unplanned miscarriages.

Incidence, and preoperative and intraoperative prognostic factors of deep venous thrombosis in patients with glioma following craniotomy

OBJECTIVES

The aim of this study was to investigate the incidence of deep vein thrombosis (DVT) and the preoperative and intraoperative risk factors associated with DVT in glioma patients METHODS: We conducted a retrospective analysis of data obtained from glioma patients at Sanbo Hospital (Beijing, China) between 2018 and 2021. Symptomatic DVT was confirmed by Doppler ultrasonography. Multivariable logistic regression analysis was used to identify preoperative and intraoperative characteristics associated with DVT. Basic clinical variables and laboratory results were analyzed.

RESULTS

A total of 492 glioma patients were included. Of these, 73 (14.84%) developed DVT, and three (0.61%) developed DVT and pulmonary embolism (PE). Multivariate analyses revealed that the following factors were highly predictive of post-operative DVT: older age ranges of 46--55 years (odds ratio [OR]: 2.94; 95% confidence interval [CI]: 1.41--6.13; p = 0.004), 56--65 years (OR: 7.86; 95% CI: 3.63--17.03; p < 0.001), and > 65 years (OR: 4.94; 95% CI: 1.83--13.33; p = 0.002); partial thromboplastin time (APTT; OR: 0.91; 95% CI: 0.84--1.00; p = 0.040); D-dimer (OR: 2.21; 95% CI: 1.28--3.82; p = 0.005); and surgery duration (OR: 2.87; 95% CI: 1.6 --5.07; p < 0.001) CONCLUSIONS: Older age, preoperative APTT, D-dimer, and surgery duration independently increased the risk of developing postoperative DVT. These findings may facilitate the development of a thrombosis risk score that will allow physicians to develop individualized strategies to prevent DVT as early as possible.

Serological Parameters and Vascular Investigation for a Better Assessment in DVT during Pregnancy-A Systematic Review

Pregnancy and the postpartum period represent a condition characterized by a thrombotic predisposition. The majority of pregnant women do not face acute or severe thrombotic events. In general, mild inconveniences such as leg swelling or moderately painful thrombotic events (phlebitis) are encountered. However, when pregnancy is associated with inherited or acquired deficits that affect homeostasis, the risk of acute or even life-threatening events can increase significantly. The major consequence is the loss of the fetus or the venous thromboembolism that endangers the mother's life. Venous thromboembolism is caused by deep vein thrombosis, therefore timely detection and especially the assessment of the extent of the thrombotic event are crucial. In this paper we have summarized the most important paraclinical investigations. The study emphasizes the importance of selecting the methods of investigation. The right choice allows establishing a correct diagnosis and individualizing the treatment.

Preoperative and intraoperative predictors of deep venous thrombosis in adult patients undergoing craniotomy for brain tumors: A Chinese single-center, retrospective study

PURPOSE

Brain tumor resection by craniotomy is associated with a high risk of deep vein thrombosis (DVT). This study evaluated the incidence and preoperative and intraoperative risk factors for DVT within 30 days of surgery.

METHODS

The analysis included: 1) basic clinical variables (patient age, sex, body mass index [BMI], tumor location, and tumor histology); 2) blood test results before operation, such as leukocytes, platelets, and coagulation parameters; and 3) surgical factors (total amount of blood lost, anesthesia mode, and surgery duration).

RESULTS

Of the 1670 patients, 206 (12.34%) had DVT and nine (0.54%) had both DVT and pulmonary embolism (PE) after surgery. Preoperative and intraoperative factors independently associated with DVT/PE were: older age 46-55 years (odds ratio [OR]: 2.87; 95% confidence interval [CI]: 1.83-4.50; P < 0.001), age 56-65 years (OR: 5.24; 95% CI: 3.27-8.40; P < 0.001), age > 65 years (OR: 6.00; 95% CI: 3.45-10.45; P < 0.001), BMI (OR: 1.03; 95% CI: 1.00-1.05; P = 0.029), activated partial thromboplastin time [APTT] (OR: 0.91; 95% CI: 0.86-0.95; P = 0.000), D-dimer (OR: 1.69; 95% CI: 1.23-2.34; P = 0.001), high-grade glioma (OR: 2.09; 95% CI: 1.28-3.40; P = 0.003), glio-neuronal (OR: 3.30; 95% CI: 1.28-8.47; P = 0.013), craniopharyngioma (OR: 2.16; 95% CI: 1.13-4.10; P = 0.019), and surgery duration (OR: 1.82; 95% CI: 1.27-2.60; P = 0.001).

CONCLUSIONS

Older age, BMI, preoperative APTT, D-dimer, tumor histology, and surgery duration independently increased the risk of developing postoperative DVT/PE. These findings provide prognostic information that will guide therapies aimed at minimizing the development of DVT/PE during hospitalization.

The risk and prevention of venous thromboembolism in the pregnant traveller

BACKGROUND

The average risk of venous thromboembolism (VTE) in long haul travellers is approximately 2.8 per 1000 travellers, which is increased in the presence of other VTE risk factors. In pregnant long-haul travellers, little is known in terms of the absolute risk of VTE in these women and, therefore, there is limited consensus on appropriate thromboprophylaxis in this setting.

OBJECTIVE

This review will provide guidance to allow practitioners to safely minimize the risk of travel-related VTE in pregnant women. The suggestions provided are based on limited data, extrapolated risk estimates of VTE in pregnant travellers and recommendations from published guidelines.

RESULTS

We found that the absolute VTE risk per flight appears to be <1% for the average pregnant or postpartum traveller. In pregnant travellers with a prior history of VTE, a potent thrombophilia or strong antepartum risk factors (e.g. combination of obesity and immobility), the risk of VTE with travel appears to be >1%. Postpartum, the risk of VTE with travel may be >1% for women with thrombophilias (particularly in those with a family history) and other transient risk factors and in women with a prior VTE.

CONCLUSIONS

Based on our findings, we recommend simple measures be taken by all pregnant travellers, such as frequent ambulation, hydration and calf exercises. In those at an intermediate risk, we suggest a consideration of 20-30 mmHg compression stockings. In the highest risk group, we suggest careful consideration for low-molecular-weight heparin thromboprophylaxis. If there are specific concerns, we advise consultation with a thrombosis expert at the nearest local centre.

Comparison of international societal guidelines for the diagnosis of suspected pulmonary embolism during pregnancy

Pregnancy-associated pulmonary embolism is one of the leading causes of maternal mortality. Diagnosis of pulmonary embolism in pregnancy is challenging, with symptoms of pulmonary embolism mimicking those of pregnancy. Several key components such as clinical prediction tools, risk stratification, laboratory tests, and imaging widely used for diagnosis of pulmonary embolism in the non-pregnant population show limitations for diagnosis in pregnancy. Further, because of the difficulty of studying pregnant patients, high-quality research evaluating the performance of these diagnostic components in pregnancy is scarce. Seven international medical society guidelines present clinical diagnostic pathways for evaluation of pulmonary embolism in pregnancy that show conflicting recommendations on the use of these diagnostic components. This Review assesses all key components of diagnostic clinical pathways recommended by guidelines for evaluation of pulmonary embolism in pregnancy, reviews current evidence, compares the guideline recommendations with respect to each key component, and provides our preferred diagnostic pathway. It provides the guidelines and available data needed for informed decision making to diagnose pulmonary embolism in pregnancy.

Could the YEARS algorithm be used to exclude pulmonary embolism during pregnancy? Data from the CT-PE-pregnancy study

INTRODUCTION

The recently proposed YEARS algorithm was shown to safely exclude pulmonary embolism (PE) and reduce the use of computed tomography pulmonary angiography (CTPA) among pregnant women with suspected PE. Our aim was to externally validate this finding.

METHODS

We performed a post hoc analysis of a prospective management outcome study for PE diagnosis in pregnant women. PE was diagnosed with an algorithm that combined the revised Geneva score, D-dimer testing, bilateral lower-limb compression ultrasonography, and CTPA. All women had a 3-month follow-up. All of the items necessary to use the YEARS algorithm were prospectively collected at the time of the study.

RESULTS

Of the 395 women included in the original study, 371 were available for the present analysis. The PE prevalence was 6.5%. Ninety-one women had no YEARS items, and 280 had one or more items. When the YEARS items were combined with D-dimer levels (<1000 ng/mL in women with no items, and <500 ng/mL in women with one or more items), 77 women (21%) met the criteria for PE exclusion and would not have undergone CTPA as per the YEARS algorithm. None of these 77 women had PE diagnosed during the initial work-up or 3-month follow-up. Therefore, the failure rate of the YEARS algorithm in our pregnant women population was 0/77 (95% confidence interval 0.0-3.9).

CONCLUSION

In our study, application of the YEARS algorithm would have resulted in safe exclusion of PE in one of five pregnant women without the need for radiation exposure, further supporting the use of the algorithm in this population.

Diagnosis of Pulmonary Embolism During Pregnancy: A Multicenter Prospective Management Outcome Study

BACKGROUND

Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism (PE) are limited, and guidelines provide inconsistent recommendations on use of diagnostic tests.

OBJECTIVE

To prospectively validate a diagnostic strategy in pregnant women with suspected PE.

DESIGN

Multicenter, multinational, prospective diagnostic management outcome study involving pretest clinical probability assessment, high-sensitivity D-dimer testing, bilateral lower limb compression ultrasonography (CUS), and computed tomography pulmonary angiography (CTPA). (ClinicalTrials.gov: NCT00740454).

SETTING

11 centers in France and Switzerland between August 2008 and July 2016.

PATIENTS

Pregnant women with clinically suspected PE in emergency departments.

INTERVENTION

Pulmonary embolism was excluded in patients with a low or intermediate pretest clinical probability and a negative D-dimer result. All others underwent lower limb CUS and, if results were negative, CTPA. A ventilation-perfusion (V/Q) scan was done if CTPA results were inconclusive. Pulmonary embolism was excluded if results of the diagnostic work-up were negative, and untreated pregnant women had clinical follow-up at 3 months.

MEASUREMENTS

The primary outcome was the rate of adjudicated venous thromboembolic events during the 3-month follow-up.

RESULTS

441 women were assessed for eligibility, and 395 were included in the study. Among these, PE was diagnosed in 28 (7.1%) (proximal deep venous thrombosis found on ultrasonography [n = 7], positive CTPA result [n = 19], and high-probability V/Q scan [n = 2]) and excluded in 367 (clinical probability and negative D-dimer result [n = 46], negative CTPA result [n = 290], normal or low-probability V/Q scan [n = 17], and other reason [n = 14]). Twenty-two women received extended anticoagulation during follow-up, mainly for previous venous thromboembolic disease. The rate of symptomatic venous thromboembolic events was 0.0% (95% CI, 0.0% to 1.0%) among untreated women after exclusion of PE on the basis of negative results on the diagnostic work-up.

LIMITATION

There were several protocol deviations, reflecting the difficulty of performing studies in pregnant women with suspected PE.

CONCLUSION

A diagnostic strategy based on assessment of clinical probability, D-dimer measurement, CUS, and CTPA can safely rule out PE in pregnant women.

PRIMARY FUNDING SOURCE

Swiss National Foundation for Scientific Research, Groupe d'Etude de la Thrombose de Bretagne Occidentale, and International Society on Thrombosis and Haemostasis.